Moraxella catarrhalis

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Moraxella catarrhalis

Moraxella catarrhalis

Moraxella catarrhalis, previously known as Micrococcus catarrhalis, Neisseria catarrhalis or Branhamella catarrhalis, is a Gram-negative, aerobic, oxidase-positive diplococcus bacteria that belong to the subgenus Branhamella of the genus Moraxella that can cause infections in children as well as adults who have weak immune systems 1, 2, 3, 4, 5. Moraxella catarrhalis is an exclusively human bacterium and was considered commensal bacteria (bacteria living in harmony with human without harming human health) in the upper respiratory tract 6, 7, 8. However, moraxella catarrhalis is a common cause of middle ear infection (otitis media) in infants and children, causing 15%-20% of acute middle ear infections (otitis media) 9, 10, 8. Moraxella catarrhalis also causes the worsening of an estimated 2 to 4 million of chronic obstructive pulmonary disease (COPD, an ongoing lung disease that damages the lungs, making it hard to breathe) in adults annually in the United States 8. In rare cases, Moraxella catarrhalis can also cause diseases that affects the whole body or multiple organs and tissues such as infective endocarditis (a life threatening infection of the heart’s inner lining and valves) and meningitis (a serious infection and inflammation of the meninges, the membranes that surround the brain and spinal cord) 3, 11.

The prevalence of Moraxella catarrhalis colonization depends on age 11. About 1 to 5% of healthy adults have upper respiratory tract colonization 4, 5. Nasopharyngeal (the upper part of the throat behind the nose or the pharynx connected with the nasal cavity) colonization with Moraxella catarrhalis is common throughout infancy, may be increased during winter months, and is a risk factor for acute middle ear infection (otitis media); early colonization is a risk factor for recurrent middle ear infection (otitis media) 11. Substantial regional differences in Moraxella catarrhalis colonization rates occur. Living conditions, hygiene, environmental factors (e.g., household smoking), genetic characteristics of the populations, host factors, and other factors may contribute to these differences 11.

Nearly all Moraxella catarrhalis strains now are resistant to penicillin by producing beta-lactamases encoded by bro-1 and bro-2 genes that code for beta-lactamases BRO-1 and BRO-2, respectively 1. Beta-lactamases produced by the Moraxella catarrhalis not only protect the pathogen but also inactivate penicillin, an antibiotic that is commonly used for the treatment of mixed infections caused by other airway pathogens such as Streptococcus pneumoniae and/or nontypeable Haemophilus influenzae 12, 13. Antibiotics such as penicillin, amoxicillin, and ampicillin are only effective against strains that do not produce beta-lactamase 14, 13, 1. More than 95% of Moraxella catarrhalis strains have been shown to resist amoxicillin and penicillin, and resistance to other classes of antibiotics is also on the rise 15, 12, 16, 17, 18. However, Moraxella catarrhalis bacteria is generally susceptible to beta-lactam+beta-lactamase inhibitors (e.g, amoxicillin/clavulanate), sulfamethoxazole, tetracyclines, second- or third-generation cephalosporins, aminoglycosides, macrolides, fluoroquinolones, and pleuromutilin (e.g., lefamulin).

Any of a number of antibiotics may be used to treat Moraxella catarrhalis infection, depending on the need for use of oral or parenteral medication, the age of the patient, any underlying conditions present, the sensitivity of the organism, and the desired spectrum of coverage 14. Amoxicillin-clavulanate, second- and third-generation oral cephalosporins, and trimethoprim-sulfamethoxazole (TMP-SMZ) are the most recommended agents 14. Alternatively, azithromycin or clarithromycin can be used.

In one study, topical use of ciprofloxacin/dexamethasone for treatment of acute otitis media with drainage that comes out of your ear (otorrhea) via tympanostomy tubes was found to have similar effectiveness to that of topical use of ofloxacin in Moraxella catarrhalis infections 19.

In another study, treatment with oral azithromycin 500 mg once daily for 3 days was found to be comparable with a 10-day regimen of oral clarithromycin 500 mg twice daily for the treatment of acute exacerbation of chronic bronchitis 20.

Telithromycin, a ketolide derivative of erythromycin A, demonstrated good in test tube activity against Moraxella catarrhalis in a study of patients with acute exacerbations of chronic bronchitis 21. However, severe liver disease associated with telithromycin use has been reported 22. Note that telithromycin is not indicated for use in patients with myasthenia gravis 14.

Moxifloxacin, a quinolone, was found to be an effective treatment of Moraxella catarrhalis– associated community-acquired pneumonia in a dosage of 400 mg/day 23.

Moraxella catarrhalis transmission

Moraxella catarrhalis, formerly known as Branhamella catarrhalis, Micrococcus catarrhalis or Neisseria catarrhalis, is a Gram-negative, aerobic, nonmotile, nonspore-forming, oxidase-positive, and catalase-positive diplococcus that exhibits gamma (γ)-hemolysis (no hemolysis) when grown on blood agar plates 24. Moraxella catarrhalis is an exclusively human bacterium and was considered normal bacterial flora in the upper respiratory tract 6, 7, 8. Studies have shown that Moraxella catarrhalis colonizes the upper respiratory tract in 28 to 100% of humans in the first year of life 25. In adults, Moraxella catarrhalis colonization rate is 1 to 10.4% 25. Moraxella catarrhalis colonization appears to be an ongoing process with an elimination-colonization turnover of various strains. Moraxella catarrhalis appears to spread contiguously from its colonizing position in the respiratory tract to the infection site. Moraxella catarrhalis infections may occur at any age. Moraxella catarrhalis specifically binds the respiratory epithelium and the extracellular matrix of the human upper respiratory tract, and it has been recovered from the biofilms of children with chronic otitis media.

Studies by Tamang et al. 26 revealed that the incidence of Moraxella catarrhalis infections was found to be the highest in the month of January. This finding is similar to those observed by Felix et al. in 1990 27, who reported a high incidence of Moraxella catarrhalis infections during the winter months. The high incidence of respiratory viral infections in autumn and winter might have a role in weakening the defence system of the respiratory tract, thereby predisposing to infection with low-grade pathogens like Moraxella catarrhalis during the winter season. Jakubicz and Leszczyńska 28, in 1997, also found that the frequency of Moraxella catarrhalis infections was higher in the autumn-winter period than in summer 26. In another study, all the isolates were obtained in colder and wetter months 1.

Moraxella catarrhalis transmission is believed to be due to direct contact with contaminated secretions by droplets. The endotoxin of Moraxella catarrhalis, a lipopolysaccharide similar to those found in Neisseria bacteria, may play a role in the disease process 25. Some strains of Moraxella catarrhalis have pili or fimbriae, which may facilitate adherence to the respiratory epithelium 25. Some Moraxella catarrhalis strains produce a protein that confers resistance to complement by interfering with the formation of the membrane attack complex. Moraxella catarrhalis also expresses specific proteins for iron uptake that act as receptors for transferrin and lactoferrin 25.

Moraxella catarrhalis has been shown to have increased cell adhesion and proinflammatory responses when cold shock (26°C for 3 hours) occurs 6, 29, 25. Physiologically, this may occur with prolonged exposure to cold air temperatures, resulting in coldlike symptoms 30.

Humoral responses against Moraxella catarrhalis appear to be age-dependent, with the titer of immunoglobulin G (IgG) gradually increasing in children 25. Antibody responses to outer-membrane proteins have been obtained, predominantly in the IgG3 subclass 25.

Moraxella catarrhalis prevention

Universal precautions, good hand-washing technique, and sterilization of instruments and tubes used in intubations, aspiration, or invasive procedures may reduce or prevent the healthcare-associated infections caused by Moraxella catarrhalis (an infection that occurs in a healthcare facility and is not present at the time of admission) 31. Cessation of smoking and prevention of passive smoking may reduce Moraxella catarrhalis infections 31. Good general health habits (eg, proper rest, exercise, and diet) are helpful as well.

Research is under way to create a vaccine to prevent Moraxella catarrhalis infections 32, 33, 34. It is projected that 4.2 million episodes of otitis media would be prevented by a combined pneumococcal-nontypeable H influenzae–Moraxella vaccine 35.

Moraxella catarrhalis signs and symptoms

Moraxella catarrhalis is an exclusively human bacterium and was considered normal bacterial flora in the upper respiratory tract 6, 7, 8. Moraxella catarrhalis is a common cause of middle ear infection (otitis media) and sinusitis (an inflammation or infection of the tissues in your sinuses) and an occasional cause of laryngitis (an infection the voice box or larynx) 36. The most significant infections caused by Moraxella catarrhalis are upper respiratory tract infections (URTIs) such as middle ear infection (otitis media) and sinusitis in children and lower respiratory tract infections (LRTIs) in adults. Infections with Moraxella catarrhalis in adults are more common if underlying conditions are present, especially if the patient is elderly.

Moraxella catarrhalis is the third most common cause of middle ear infection (otitis media) and sinusitis in children (after Streptococcus pneumoniae and Haemophilus influenzae). Moraxella catarrhalis causes bronchitis and pneumonia in children and adults with underlying chronic lung disease and is occasionally a cause of bacteremia and meningitis, especially in people with weak immune system 37, 38. Bacteremia can be complicated by local infections, such as bone infection (osteomyelitis) or joint infection (septic arthritis). Moraxella catarrhalis is also associated with nosocomial infections also known as healthcare-associated infections or hospital-acquired infections, which are infections that develop in a healthcare facility while a patient is receiving medical treatment.

Moraxella catarrhalis infection signs and symptoms are similar to infections with other organisms in the same location.

Common cold

Common cold is an illness affecting your nose and throat.

Common cold symptoms can include:

  • Runny or stuffy nose (often with green- or yellow-colored discharge).
  • Sore or scratchy throat.
  • Cough.
  • Sneezing.
  • Generally feeling unwell or fatigue.
  • Slight body aches, muscle aches or a mild headache.
  • Low-grade fever up to 102°F (38.9°C).

The mucus from your nose may start out clear and become thicker and yellow or green. This change is normal.

These conditions can occur along with your common cold:

  • Middle ear infection (otitis media). This is the swelling and build-up of fluids in the space behind the eardrum. It may be caused by a virus or bacteria. Typical signs and symptoms include earaches or the return of a fever following a common cold.
  • Asthma. A common cold can trigger wheezing, even in people who don’t have asthma. For people with asthma, a cold can make it worse.
  • Sinusitis. In adults or children, a common cold that lasts a while can lead to swelling and pain in the sinuses. These are air-filled spaces in the skull above the eyes and around the nose. A virus or bacteria may cause sinusitis.
  • Lower respiratory tract infections (LRTI). A common cold can lead to infection or inflammation of the lungs, such as pneumonia or bronchitis. People with asthma or weak immune systems have an increased risk of these conditions.

In 29% of common-cold episodes due to bacterial pathogens including Moraxella catarrhalis, affected children continued to be symptomatic 10 days after the first appearance of symptoms 39.

Middle ear infection (acute otitis media)

A clinical history of acute middle ear infection (acute otitis media) and the middle ear with fluid (otitis media fluid with effusion without an infection) with symptoms includes ear ache or pain (otalgia), fever, and hearing loss. Middle ear infection (acute otitis media) is a very common condition, especially in children. Approximately 70% of children experience at least 1 episode of otitis media during childhood. Moraxella catarrhalis has been isolated in 3 to 17.3% of middle ear exudates in children with otitis media 40, 41.

Otitis media with effusion or the middle ear with fluid (effusion) without bacterial or viral infection may occur because the fluid buildup persists after an ear infection has gotten better. It may also occur because of some dysfunction or noninfectious blockage of the eustachian tubes. Children between the ages of 6 months and 2 years are more susceptible to ear infections because of the size and shape of their eustachian tubes and because their immune systems are still developing.

Children who have otitis media with effusion (the middle ear with fluid) may not have any symptoms. Usually they don’t act sick. Children could experience the following:

  • A feeling of fullness in the ear.
  • Muffled hearing.
  • Fluid that drains from the ears (if the eardrum has ruptured).
  • Some pain inside the ear (if your child is too young to speak and tell you his or her ear hurts, he or she may tug at the ear often).

If your child’s otitis media with effusion develops into an infection, he or she may have other symptoms. These include:

  • Pain in the ear (crying or pulling at the ear for very young children).
  • Ear pain, especially when lying down
  • Fever of 100 °F (38 °C) or higher
  • Tugging or pulling at an ear
  • Trouble sleeping
  • Crying more than usual
  • Fussiness
  • Trouble hearing or responding to sounds
  • Not feeling like eating, loss of appetite or sleeping
  • Loss of balance
  • Drainage of fluid from the ear
  • Headache.

Signs and symptoms of an ear infection can indicate several conditions. It’s important to get an accurate diagnosis and prompt treatment. See your child’s doctor if:

  • Symptoms last for more than a day
  • Symptoms are present in a child less than 6 months of age
  • Ear pain is severe
  • Your infant or toddler is sleepless or irritable after a cold or other upper respiratory infection
  • You observe a discharge of fluid, pus or bloody fluid from the ear.

Middle ear infection (acute otitis media) signs and symptoms in adults include:

  • Ear pain
  • Drainage of fluid from the ear
  • Trouble hearing

Most ear infections don’t cause long-term complications. Ear infections that happen again and again can lead to serious complications:

  • Hearing loss. Mild hearing loss that comes and goes is fairly common with an ear infection, but it usually gets better after the infection clears. Ear infections that happen again and again, or fluid in the middle ear, may lead to more-significant hearing loss. If there is some permanent damage to the eardrum or other middle ear structures, permanent hearing loss may occur.
  • Speech or developmental delays. If hearing is temporarily or permanently impaired in infants and toddlers, they may experience delays in speech, social and developmental skills.
  • Spread of infection. Untreated infections or infections that don’t respond well to treatment can spread to nearby tissues. Infection of the mastoid, the bony protrusion behind the ear, is called mastoiditis. This infection can result in damage to the bone and the formation of pus-filled cysts. Rarely, serious middle ear infections spread to other tissues in the skull, including the brain or the membranes surrounding the brain (meningitis).
  • Tearing or rupturing of the eardrum. Most eardrum tears heal within 72 hours. In some cases, surgical repair is needed.

Sinus infection (sinusitis)

In a patient with sinus infection (sinusitis), the clinical history commonly includes headache, pain in the maxillary or frontal area, fever, and cough. Young children present with persistent nasal discharge (lasting longer than 2 weeks) and cough, especially at night. Moraxella catarrhalis has been isolated in 22% of maxillary sinus aspirates in children as a single pathogen and in 72% of aspirates in combination with other organisms (eg, Streptococcus pneumoniae or Haemophilus influenzae) 42.

The symptoms of acute sinus infection (acute sinusitis) include:

  • Pain, tenderness, swelling and pressure around the eyes, cheeks, nose or forehead that gets worse when bending over.
  • Headache
  • Blocked or stuffy nose, known as congestion. This makes it hard to breathe through the nose.
  • Changed sense of smell.
  • Fever
  • Coughing, which may be worse at night
  • Thick, yellow or greenish mucus from the nose, known as a runny nose, or down the back of the throat, known as postnasal drip.
  • Reduced sense of smell and taste
  • Weakness or fatigue
  • Toothache
  • Bad breath (halitosis).

The following can raise your risk of getting sinusitis:

  • Hay fever or another allergy that affects the sinuses.
  • A common cold that affects the sinuses.
  • A problem inside the nose, such as a deviated nasal septum, nasal polyps or tumors.
  • A medical condition such as cystic fibrosis or an immune system disorder such as HIV/AIDS.
  • Being around smoke, either from smoking or being around others who smoke, known as secondhand smoke.

Most people with acute sinusitis don’t need to see a doctor.

However, contact your doctor if you have any of the following:

  • Symptoms that last more than a week.
  • Symptoms that get worse after seeming to get better.
  • A fever that lasts.
  • A history of repeated or chronic sinusitis.

See a doctor immediately if you have symptoms that might mean a serious infection:

  • Pain, swelling or redness around the eyes.
  • High fever.
  • Confusion.
  • Double vision or other vision changes.
  • Stiff neck.

Lower respiratory tract infections (LRTIs)

Lower respiratory tract infections (LRTIs) are infections that affect the airways below the level of the larynx, including the trachea and the alveolar sacs. Lower respiratory tract infections (LRTIs) are characterized in many different ways. Acute infections that affect the airways include acute bronchitis, bronchiolitis and influenza, whereas acute infections that affect the alveolar sacs can include pneumonia. In adult patients who have a history of conditions such as chronic obstructive pulmonary disease (COPD), pneumoconiosis, asthma, cancers or weak immune system and who show findings characteristic of bronchitis or pneumonia or worsening of their underlying condition, Moraxella catarrhalis infection is a possibility. Moraxella catarrhalis respiratory tract infection is also associated with smoking. Moraxella catarrhalis is isolated from sputum and transtracheal aspirate specimens at rates of 0.2 to 8.1%, accompanied by Haemophilus influenzae and/or Streptococcus pneumoniae in more than 30% of cases 43, 44, 45, 46.

In children, lower respiratory tract infections (LRTIs) have been associated with a history of recent respiratory syncytial virus (RSV) or cytomegalovirus (CMV) infection or with more debilitating conditions, such as bronchopulmonary dysplasia, ventricular septal defect, leukemia, Arnold-Chiari malformation, prematurity, or HIV infection 47, 48.

The main symptom of a lower respiratory tract infection (LRTI) is cough, which can be severe. Your child may have a dry cough or a wet cough. Even if it is a wet cough, he or she may not be able to cough up phlegm/mucus.

Other symptoms of a lower respiratory tract infection (LRTI) include:

  • Fever
  • Tightness in the chest or chest pain
  • Breathing quickly or in an irregular pattern
  • Difficulty catching your breath
  • Wheezing
  • Overall change in well-being (decreased energy, appetite and fluid intake)

Respiratory syncytial virus (RSV)

Respiratory syncytial virus (RSV) causes infections of the lungs and respiratory tract. Respiratory syncytial virus (RSV) is so common that most children have been infected with the virus by age 2. Respiratory syncytial virus (RSV) can also infect adults. In adults and older, healthy children, respiratory syncytial virus (RSV) symptoms are mild and typically mimic the common cold. Respiratory syncytial virus (RSV) can cause severe infection in some people, including babies 12 months and younger (infants), especially premature infants, older adults, people with heart and lung disease, or anyone with a weak immune system (immunocompromised).

Respiratory syncytial virus (RSV) signs and symptoms most commonly appear about four to six days after exposure to the virus. In adults and older children, RSV usually causes mild cold-like signs and symptoms. These may include:

  • Congested or runny nose
  • Dry cough
  • Low-grade fever
  • Sore throat
  • Sneezing
  • Headache

In severe cases, RSV infection can spread to the lower respiratory tract, causing pneumonia or bronchiolitis — inflammation of the small airway passages entering the lungs. Signs and symptoms may include:

  • Fever
  • Severe cough
  • Wheezing — a high-pitched noise that’s usually heard on breathing out (exhaling)
  • Rapid breathing or difficulty breathing — the person may prefer to sit up rather than lie down
  • Bluish color of the skin due to lack of oxygen (cyanosis)

Infants are most severely affected by RSV. Signs and symptoms of severe RSV infection in infants include:

  • Short, shallow and rapid breathing
  • Struggling to breathe — chest muscles and skin pull inward with each breath
  • Cough
  • Poor feeding
  • Unusual tiredness (lethargy)
    Irritability

Most children and adults recover in one to two weeks, although some might have repeated wheezing. Severe or life-threatening infection requiring a hospital stay may occur in premature infants or in anyone who has chronic heart or lung problems.

Bronchiolitis

Bronchiolitis is a common lung infection in young children and infants. Bronchiolitis causes swelling and irritation and a buildup of mucus in the small airways of the lungs (bronchioles). This makes it harder for the child to breathe. Bronchiolitis is usually caused by a virus. Respiratory syncytial virus (RSV) is the most common cause. Young children under age 2, particularly those between 3 months and 6 months old, get bronchiolitis most often. It peaks in winter and early spring. Babies born prematurely are at a much higher risk of complications from respiratory syncytial virus (RSV).

Bronchiolitis starts out with symptoms much like a common cold. Your child may have a runny nose, cough, and a slight fever for a few days. After that, your child may begin to breathe fast and wheeze (make a high-pitched whistling sound when breathing). Sometimes children have trouble breathing. Symptoms of bronchiolitis can last for 1 to 2 weeks but occasionally can last longer.

Most children get better with care at home. A small number of children need a stay in the hospital.

Get medical attention right away if your child has any of these symptoms:

  • Your child is vomiting and can’t keep liquids down.
  • Your child is breathing very fast, more than 40 breaths in 1 minute — with short, shallow breaths.
  • You child can’t breathe easily and the ribs seem to suck inward when breathing in or your child has to sit up to be able to breathe.
  • Struggles to breathe and can’t speak or cry.
  • Refuses to drink enough, or breathes too fast to eat or drink.
  • Makes wheezing sounds when breathing.
  • Makes grunting noises with each breath.
  • Appears slow moving, weak or very tired.
  • Your child has had heart disease or was born prematurely. In this case, see your child’s doctor at the first signs of bronchiolitis.

If your child’s lips or fingertips look bluish, he or she may not be getting enough oxygen. Seek medical care or go to the emergency room right away.

Acute bronchitis

Bronchitis is an inflammation of the lining of your bronchial tubes. The bronchial tubes carry air into and from your lungs. When these tubes get infected, they swell. People who have bronchitis have mucus (thick fluid) forms inside their bronchial tubes and this narrows the airways, making it harder for you to breathe. People who have bronchitis often cough up thickened mucus, which can be discolored. Bronchitis may start suddenly and be short term (acute) or start gradually and become long term (chronic).

  • Acute bronchitis, which often develops from a cold or other respiratory infection, is very common. Also called a chest cold, acute bronchitis usually improves within a week to 10 days without lasting effects, although the cough may linger for weeks.
  • Chronic bronchitis, a more serious condition, is a constant irritation or inflammation of the lining of the bronchial tubes, often due to smoking. If you have repeated bouts of bronchitis, you may have chronic bronchitis, which requires medical attention. Chronic bronchitis is one of the conditions included in chronic obstructive pulmonary disease (COPD).

If you have acute bronchitis, you may have cold symptoms, such as:

  • Cough that brings up clear, white, yellowish-gray, or green mucus (sputum) — rarely, it may be streaked with blood
  • Chest congestion or tightness
  • Shortness of breath
  • Wheezing
  • Sore throat
  • Mild headache and body aches
  • Slight fever and chills
  • Fatigue
  • Chest discomfort.

While these symptoms usually improve in about a week, you may have a nagging cough that lingers for several weeks. This happens because the bronchial tubes take a while to heal. A lasting cough may signal another problem, such as asthma or pneumonia.

See your doctor if your cough:

  • Is accompanied by a fever higher than 100.4 °F (38 °C).
  • Produces blood.
  • Is associated with serious or worsening shortness of breath or wheezing.
  • Includes other serious signs and symptoms, for example, you appear pale and lethargic, have a bluish tinge to your lips and nail beds, or have trouble thinking clearly or concentrating.
  • Lasts more than three weeks.

Pneumonia

Pneumonia is an infection that inflames the air sacs (alveoli) in one or both lungs. The air sacs (alveoli) may fill with fluid or pus (purulent material), causing cough with phlegm or pus, fever, chills, and difficulty breathing. This causes a variety of symptoms, which range from mild to severe. A variety of organisms, including bacteria, viruses and fungi, can cause pneumonia.

How serious pneumonia is depends on many factors. Pneumonia can range in seriousness from mild to life-threatening. Pneumonia is most serious for infants and young children, people older than age 65, and people with health problems or weakened immune systems.

The signs and symptoms of pneumonia vary from mild to severe, depending on factors such as the type of germ causing the infection, and your age and overall health. Mild signs and symptoms often are similar to those of a cold or flu, but they last longer.

Signs and symptoms of pneumonia may include:

  • Chest pain when you breathe or cough
  • Confusion or changes in mental awareness (in adults age 65 and older)
  • Cough, which may produce phlegm or mucus
  • Fatigue
  • Fever, sweating and shaking chills
  • Lower than normal body temperature (in adults older than age 65 and people with weak immune systems)
  • Shortness of breath or difficulty breathing.

You may also sweat, have a headache, and feel very tired. Some people also experience nausea, vomiting, and diarrhea.

Newborns and infants may not show any sign of the infection. Or they may vomit, have a fever and cough, appear restless or tired and without energy, or have difficulty breathing and eating.

If any of these symptoms are severe, see your doctor. You should also see your doctor if you suddenly start getting worse after having a cold or the flu.

See your doctor if you have difficulty breathing, chest pain, persistent fever of 102 °F (39 °C) or higher, or persistent cough, especially if you’re coughing up pus.

It’s especially important that people in these high-risk groups see a doctor:

  • Adults older than age 65
  • Children younger than age 2 with signs and symptoms
  • People with an underlying health condition or weakened immune system
  • People receiving chemotherapy or taking medication that suppresses the immune system

For some older adults and people with heart failure or chronic lung problems, pneumonia can quickly become a life-threatening condition.

Nosocomial infections

Outbreaks of nosocomial infections with Moraxella catarrhalis have been reported, mostly involving pulmonary units or pediatric intensive care units (PICUs).

Bacteremia

Bacteremia, also known as a bloodstream infection (BSI) or blood poisoning, is a condition where bacteria are present in the blood. In 46% of patients with Moraxella catarrhalis bacteremia, no primary site of infection is found. Bacteremia is rare with Moraxella catarrhalis community-acquired pneumonia 49.

The following conditions have been found to predispose to Moraxella catarrhalis bacteremia:

Bacteremia can be asymptomatic or cause a mild fever. Bacteremia can be serious, especially for people with weak immune systems. Without treatment, bacteremia can progress to sepsis, which can cause organ failure and death. Bacteremia is treated with antibiotics. Timely treatment is necessary to prevent complications.

If bacteremia progresses to sepsis or septic shock, symptoms may include:

  • Chills
  • Fast heart rate (tachycardia)
  • Low blood pressure (hypotension)
  • Abdominal pain
  • Nausea and vomiting
  • Diarrhea
  • Rapid breathing (hyperventilation)

Sepsis is a life-threatening medical emergency that occurs when the body’s immune response to an infection or injury becomes extreme and damages the body’s own tissues and organs.

Septic shock is the last and most severe stage of sepsis. Septic shock is defined by dangerously low blood pressure, despite lots of IV (intravenous) fluids. You need immediate treatment if you have septic shock. Treatment may include antibiotics, oxygen and medication.

Early signs of sepsis can include:

  • Fast heart rate.
  • Fever or hypothermia (low body temperature).
  • Shaking or chills.
  • Warm, clammy or sweaty skin.
  • Confusion or disorientation.
  • Hyperventilation (rapid breathing).
  • Shortness of breath.

When sepsis turns to septic shock, you may experience additional symptoms. These include:

  • Very low blood pressure.
  • Lightheadedness.
  • Little or no urine output.
  • Heart palpitations.
  • Cool and pale limbs.
  • Skin rash.

Endocarditis and other local infections

Moraxella catarrhalis endocarditis (inflammation or infection of your heart’s inner lining and valves) has been described in patients with a history of heart valve conditions or prostheses, as well as in patients who were previously healthy. Moraxella catarrhalis endocarditis has also been described as a complication of balloon angioplasty 50, 51. Moraxella catarrhalis has been identified as a pathogen in cleft palate repairs resulting in a higher fistula rate 52.

Sporadic cases of other infections with Moraxella catarrhalis include the following:

  • Meningitis (a serious inflammation of the meninges, the membranes that surround the brain and spinal cord)
  • Ophthalmia neonatorum, also known as neonatal ophthalmia or neonatal bacterial conjunctivitis, is a bacterial eye infection that occurs in newborns during the first month of life
  • Septic arthritis (a rare and serious joint infection that affects one or more of your joints) 53
  • Keratitis (an inflammation of the cornea — the clear, dome-shaped tissue on the front of your eye that covers the pupil and iris) 54
  • Urinary tract infection (UTI) an infection in any part of the urinary system. The urinary system includes the kidneys, ureters, bladder and urethra.
  • Wound infection
  • Peritonitis is an inflammation of the peritoneum (a membrane, a sheet of smooth tissue that lines your abdominopelvic cavity and surrounds your abdominal organs) in patients on dialysis
  • Conjunctivitis
  • Periorbital cellulitis also known as preseptal cellulitis (a bacterial infection that affects the eyelid and the skin around your eyes) 55. Periorbital cellulitis affects kids more commonly than adults.
  • Acute urethritis (an inflammation or infection of the urethra, the tube that carries urine from the bladder out of the body) resembling gonorrhea 56.

Moraxella catarrhalis complications

Complications of Moraxella catarrhalis infection depend on the site of infection, the underlying conditions, your age, your health status and immune system may include the following 57, 58:

  • Recurrence
  • Bacteremia and sepsis
  • Meningitis (a serious inflammation or infection of the meninges, the membranes that surround the brain and spinal cord)
  • Mastoiditis (a bacterial infection of the mastoid bone, which is located behind the ear in the skull). The mastoid bone is made up of air cells that drain the middle ear. Mastoiditis is usually caused by a middle ear infection, but can also be caused by other factors.
  • Hearing loss
  • Pleural effusion (the buildup of excess fluid between the layers of the pleura outside your lungs)
  • Septic shock (a life-threatening medical condition that occurs when the body doesn’t have enough blood circulating, which means organs and cells don’t get enough oxygen and nutrients to function properly)
  • Death

Moraxella catarrhalis diagnosis

Various diagnostic studies and procedures may be warranted, depending on the site of Moraxella catarrhalis infection and underlying conditions. For example, doctors diagnose acute middle ear infection (otitis media) by using a handheld light called an otoscope to look for bulging and redness of the eardrum and for fluid behind the eardrum. Your doctor may need to clean wax from your ear first so he/she can see more clearly. Doctors may use a rubber bulb and tube attached to the otoscope to squeeze air into the ear to see if the eardrum moves. If the eardrum does not move or moves only slightly, fluid in the middle ear, which is one sign of infection, may be present.

Confirmation of the diagnosis of Moraxella catarrhalis infection is based on isolation of the organism in culture.

Although colonization is more common in children, only a small percentage of positive cultures findings have clinical significance in children. In one study, 9% of cultures positive for Moraxella catarrhalis in children younger than 5 years and 33% of isolates from children aged 6-10 years were found to be clinically significant 59. However, all cultures positive for Moraxella catarrhalis had clinical importance in adults 59. In one study involving adult patients, the male-to-female ratio was 1.6:1 59.

Moraxella catarrhalis cultures can be taken from middle ear effusion, the nasopharynx, sputum, sinus aspirates, transtracheal or transbronchial aspirates, blood, peritoneal fluid, wounds, or urine 60. Moraxella catarrhalis colonies are approximately 0.2 cm in diameter, opaque, and non-hemolytic after incubation on chocolate or blood agar for 48 hours 60. Characteristically, Moraxella catarrhalis colonies can be pushed along the surface of the agar like a hockey puck 60.

Gram-negative diplococci are found on Gram staining of cultures 60. Strict adherence to the staining protocol is required. The accuracy of Gram staining for isolation of Neisseria or Moraxella species has been reported to agree perfectly with identification by culture 61.

With standard methods of identification, Moraxella catarrhalis can be differentiated from Neisseria species by not using sucrose, glucose, maltose, and lactose 60. Because Neisseria cinerea exhibits the same reaction pattern, the Superoxyl test must be added 60. For definitive identification, deoxyribonuclease (DNase) and nitrate reduction tests are performed; Moraxella catarrhalis produces DNase and reduces nitrate and nitrite levels 60.

Several rapid confirmatory tests are available to identify Moraxella catarrhalis, and they are all based on the ability of Moraxella catarrhalis to hydrolyze tributyrin 60. This provides immediate identification and separation from human Neisseria species, which do not hydrolyze tributyrin 60.

Serologic tests for infections with Moraxella catarrhalis are not widely used; cross-reactivity with Neisseria species in the detection of complement fixation antibodies by immunoelectrophoresis has been demonstrated 60. Serum antibodies to whole-cell proteins, to lipo-oligosaccharides, and to outer-membrane antigens have proved useful in the diagnosis of Moraxella catarrhalis infection 60. Other laboratory studies may be needed, depending on the site of infection and underlying conditions 60.

Imaging studies

Imaging studies (eg, plain radiography or computed tomography [CT]) may be needed, depending on the site of infection. Paranasal sinus radiography or CT scanning may be helpful. Chest radiography is often performed. If peritonitis is a possibility, abdominal radiography using a 3-way view is indicated.

Moraxella catarrhalis treatment

Moraxella catarrhalis infection treatment depends on the infection site, age of the patient, underlying condition(s), and severity of the disease. Consultation with an ear, nose, and throat (ENT) specialist may be indicated in recurrent cases of otitis or sinusitis. Consultation with an infectious disease specialist is recommended for infections that do not respond to antibiotic treatment, infections in patients with underlying debilitating conditions, systemic infections with Moraxella catarrhalis, or infections in unusual locations 62.

Follow-up care with the patient’s primary care physician is highly recommended. Worsening symptoms warrant a return visit to the primary care physician 62.

Moraxella catarrhalis antibiotic

Approximately 95% of Moraxella catarrhalis strains isolated in the United States produce beta-lactamase. Beta-lactamases produced by the Moraxella catarrhalis not only protect the pathogen but also inactivate penicillin, an antibiotic that is commonly used for the treatment of mixed infections caused by other airway pathogens such as Streptococcus pneumoniae and/or nontypeable Haemophilus influenzae 12, 13. Antibiotics such as penicillin, amoxicillin, and ampicillin are only effective against strains that do not produce beta-lactamase 14, 13, 1. More than 95% of Moraxella catarrhalis strains have been shown to resist amoxicillin and penicillin, and resistance to other classes of antibiotics is also on the rise 15, 12, 16, 17, 18.

Any of a number of antibiotics may be used to treat Moraxella catarrhalis infection, depending on the need for use of oral or parenteral medication, the age of the patient, any underlying conditions present, the sensitivity of the organism, and the desired spectrum of coverage 14. Amoxicillin-clavulanate, second- and third-generation oral cephalosporins, and trimethoprim-sulfamethoxazole (TMP-SMZ) are the most recommended agents 14. Alternatively, azithromycin or clarithromycin can be used.

In one study, topical use of ciprofloxacin/dexamethasone for treatment of acute otitis media with drainage that comes out of your ear (otorrhea) via tympanostomy tubes was found to have similar effectiveness to that of topical use of ofloxacin in Moraxella catarrhalis infections 19.

In another study, treatment with oral azithromycin 500 mg once daily for 3 days was found to be comparable with a 10-day regimen of oral clarithromycin 500 mg twice daily for the treatment of acute exacerbation of chronic bronchitis 20.

Telithromycin, a ketolide derivative of erythromycin A, demonstrated good in test tube activity against Moraxella catarrhalis in a study of patients with acute exacerbations of chronic bronchitis 21. However, severe liver disease associated with telithromycin use has been reported 22. Note that telithromycin is not indicated for use in patients with myasthenia gravis 14.

Moxifloxacin, a quinolone, was found to be an effective treatment of Moraxella catarrhalis– associated community-acquired pneumonia in a dosage of 400 mg/day 23.

Moraxella catarrhalis prognosis

Moraxella catarrhalis infection prognosis is poor in hospitalized patients with underlying conditions, especially the following 63:

  • Patients hospitalized for prolonged periods
  • Patients in pulmonary units or pediatric intensive care units
  • Patients of advanced age

In a study of 42 cases of pneumonia with Moraxella catarrhalis isolated as the single agent in sputum cultures, the mortality rate attributable to the underlying problems within 3 months of pneumonia was 45% 64.

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